The challenge. Hawaii's island of Maui has the fastest-growing and longest-living senior population in the nation—a so-called "silver tsunami" that if unchecked, is predicted to inundate existing supports and services.
The gap in services for the frailest of these elders reached a crisis in 2000. Patients were "stacking up" in the local hospital because there were no beds available in long-term-care facilities. A community partnership, formed to uncover the reasons for the problem, discovered that there was also a severe shortage of home-based and community-based health care to support older adults who desired to stay in their homes.
The partnership got a planning grant through RWJF's Community Partnerships for Older Adults national program to create a strategy for addressing Maui's long-term-care problem. Rita Barreras, retired director of aging and adult services for the state of Colorado, joined the partnership as its director in 2002.
Background. In the tiny rural town of Las Animas, Colorado, where Barreras grew up, neighbors looked out for each other. Barreras was no more than 5 or 6 years old when she began accompanying her mother on visits to elderly shut-ins. "We were in there helping sweep the house while she cooked for them," Barreras recalled. "She taught all her kids how to stay involved with the community and always to give back."
Barreras went to college to become a social worker but "after doing my internship at a mental health center," she said, "I discovered that was not what I wanted to do."
A job doing research on human services and health programs convinced Barreras that she was better suited for administration and management. She earned a masters degree in urban affairs at the University of Colorado in Denver, and began what would become a long career in state government.
Barreras administered an array of social service programs in Colorado that served people across the lifespan—Medicaid, Aid for Dependent Children and aging services, among them. At age 50, she took early retirement with a plan to move to Hawaii, where her husband had once lived.
A work colleague in the state agency on aging in Oahu told her about a job opening in an unusual community partnership in Maui that was attempting to reshape the island's long-term-care services. Barreras interviewed on the phone and got the director's job—sight unseen.
The Maui culture, with its strong community connections and respect for elders, reminded Barreras of her Hispanic origins. "There is the concept here called o'hana," she said. "You have families living in a larger home and a cottage out back for the grandparents. My grandparents were right next to us when we grew up. That was very much a way of life, like it is here."
The "talk story" tradition. As comfortable as Barreras felt in her new home, she was a "mainlander" and needed to gain the trust of Maui residents. Armed with batches of fresh brownies, she traveled around the island, sharing potluck lunches, and listening to people's stories and concerns.
Her embrace of the "talk story" tradition—where everyone gets a chance to speak, and everyone else must listen patiently and show interest until it's their turn—drew people into the partnership, even in the most remote parts of the island.
"I think part of it was my salt and pepper hair," Barreras said. "People kept telling me that I felt local to them. Personality-wise they accepted me like a Kama'aina, meaning 'of the land.'"
In Hana—a town of 1,800 people reached by driving through 56 one-way bridges—community leaders were surprised to learn that caring for elders was a crisis and a priority all over the island. "It was like 'wow, we thought the issues belonged only to us,'" Barreras recalled.
Community leaders in Hana and other small towns were unaccustomed to being asked to participate in a broad-based coalition—such initiatives usually originated out of the big urban areas of Honolulu or Oahu. "What this grant did was bring an opportunity to a neighbor island to test a model for involving citizens in an important issue," Barreras said.
"Coalition building means sharing power with the citizens," Barreras said. "With the partnership, everyone who came to the table was an equal."
Laboratories for Change. The partnership formed six regional planning groups—or laboratories of change, as Barreras prefers to call them—to identify the top three or four issues in their part of the island. All of the regional leaders, some 85 people, converged for a summit in June 2003 where they zeroed in on four strategic goals for the partnership:
- To improve access to information about long-term care services
- To increase awareness and knowledge at all levels of society about aging, long-term care and supportive services
- To provide education and training to long-term-care caregivers in both informal home-based and formal professional situations
- To develop, implement and sustain an organized long-term-care infrastructure for Maui Island that matches the community's needs and preferences
"I have never been in a community where collaboration is so high," Barreras said. "That is particularly a trait of Maui. That helped me in pulling this coalition together."
Having agreed on their marching orders, the partnership applied for and received a second, four-year Community Partnerships for Older Adults grant to implement their plan to improve care systems for older adults.
Progress is made. The partnership has made significant progress on all fronts. The group:
- Created a directory of all aging and long-term-care services in Maui that was incorporated into the County's online Aging and Disability Resource Center
- Developed a training curriculum, covering topics such as aging with aloha, respecting elders and compassionate caring, that was included in classes offered in 2008 through the Maui Community College
- Started a caregiving curriculum and career shadowing program for students at four Maui high schools that covers the challenges of aging, types of aging services, and the structure and function of the aging services system
- Launched a program to recruit and train volunteers who were interested in becoming paid caregivers for older adults
- Collaborated with the State Department of Human Services Director to push for legislation to update building codes in Hawaii so that assisted-living facilities could operate fully as such
- Supported an initiative called the Going Home Program, which allows discharges of long-term care clients from hospitals to a more cost-effective foster family setting. A simple change in an administrative rule allowed Medicaid dollars to follow the client and resulted in statewide savings to the Medicaid program of approximately $50 million over three years.
The Hana retrofit story. One story perhaps captures best the spirit of the work the partnership undertook, Barreras said.
In tiny and remote Hana, a two-and-a-half hour's drive from the closest assisted-living programs or nursing homes, a group of elders had determined they wanted to "age in place." Their homes were filled with barriers, though, that made that dream unsafe and unlikely.
The coordinator of the partnership's regional planning group, who ran a nonprofit in Hana, contacted the shop teacher at the high school and the two created a mentoring program to teach students the carpentry trade. The students put their new knowledge and skills to work retrofitting 19 homes—including installing ramps, putting in grab bars and raising toilet seats. Local businesses donated most of the building materials.
Besides making the homes safer, the project built a bridge between the seniors and the youth, Barreras said. "The relationship was not strong when they started. These were kids who were having trouble in high school. It changed their relationship."
The "Hana retrofit project" has had unexpected ripple effects. Statistics gathered at the time found that the average cost for refitting the 19 homes was $800 each—far less than the average medical cost of treating a fall, estimated at $1,728. Those findings were published in the March 2008 issue of the Hawai'i Medical Journal to show how home modifications for the elderly were a cost-efficient way to prevent falls. ("Cost Benefit Considerations of Preventing Elderly Falls through Environmental Modifications to Homes in Hana," 2008. Available online.)
Other high school carpentry classes are being encouraged to duplicate the Hana efforts for elders in their communities. And across the state, the concept of house planning is being restructured with longevity built into the blueprints from the start.
The beat goes on. The Hana story reflects what the partnership's leaders believe is a sea change in how Maui citizens think about aging well. In April 2008, the partnership trademarked a new name—the Aging with Aloha® Coalition—to match that hoped-for goal. Aging with Aloha continues to operate, with reduced staff, under the auspices of the Tri-Isle Resource Conservation and Development Council. Most recently the coalition has been invited to submit a proposal for Island Innovation Fund consideration through the Hawaii Community Foundation in support of a caregiving, teaching and learning initiative.
Barreras believes that Aging with Aloha is a model of civic engagement that others can replicate. In August 2010, Barreras traveled to the Big Island of Hawaii to share Maui's story at the Mayor's Health Care Conference. As a result, the Big Island Healthcare Alliance is working on the early stages of creating a model similar to Maui's, seeking advice from the Aging with Aloha Coalition. Other communities on the mainland also have asked her to consult on how to create a grassroots action plan to meet the approaching "aging tsunami" head on.
Working with a partnership is not unlike running a large state service agency, Barreras has found. Both jobs require people skills and the creativity to navigate through and around barriers and potholes. "It is all about human resource management. You have to know how to supervise, how to coach, how to get at success."
"I am task oriented. I like to solve problems," she said. "But I think it is my natural style to work in groups and to build collaboration. The big lesson for me is that collaboration is doable and it leads to success."
RWJF perspective. Community Partnerships for Older Adults was an eight-year, $28 million national initiative of the Robert Wood Johnson Foundation (RWJF) that supported 16 communities to create collaborative partnerships to address the many gaps and inefficiencies in long-term care and supportive systems for vulnerable older adults.
RWJF Program Officer Jane Isaacs Lowe notes, "One of the goals was to make what is a patchwork of long-term-care services in communities behave more like a coordinated system. We wanted to make sure that along that continuum of care, elders in communities had the breadth of services they needed.
"In general, the partnerships have demonstrated that innovations are possible in communities across the country that allow people to age in place and that make for better care delivery for people with long-term-care needs."